July 2010 Issue

In Case of Emergency — Hospital Staff Need Proper Preparation for Potential Disasters
By Karen Meno, BS, MBA, RD, LD, CPHQ, HCRM
Today’s Dietitian
Vol. 12 No 7 P. 42

Suggested CDR Learning Codes: 7060; Level 2

It’s time to think about the unthinkable.

No one likes to talk about planning for disasters, either man-made or natural. It is human nature to say, “It will never happen here.” But common sense—and daily news programs—show us that terrible events can and do happen anywhere, anytime.

Some disasters are sudden and unanticipated; some can be predicted. Disasters such as earthquakes, hurricanes, floods, and tornadoes cannot be prevented, and no matter how well designed and regulated an industry is, accidents like oil spills or mine collapses will occur. Both natural and man-made disasters place special burdens on hospitals, which have a unique role during these events: No matter how much their infrastructure, equipment, and personnel are disrupted, they must continue to not merely endure but function.

A responsible supervisor or hospital administration must prepare in advance for a “worst-case” event, which may never occur. This article will start you on your way to understanding the immediate impact and what you can do to minimize your personal anxiety and others’ anxiety before, during, and after the event.

Preparing in Advance
Remember that you are part of a comprehensive, hospitalwide disaster plan, usually called the Emergency Operations Plan (EOP). This is developed in part from a Hazard Vulnerability Analysis (HVA), a process for identifying natural and man-made hazards and the direct and indirect effects these hazards may have on a hospital. An HVA provides a tool for determining the potential demands on emergency services and other resources during a crisis so that effective preventive measures can be taken and a coordinated disaster response plan can be developed.

Because disasters usually affect a widespread area, local governments also prepare HVAs. A hospital’s HVA should consider hazards identified in the community plans that may impact the facility. Some hospital and community HVAs are developed together; in larger communities, multiple facilities will coordinate and provide input to a communitywide plan.

HVAs identify the most common types of disasters that can occur in your geographic area. Your plan should be specific to the area of the country where you live. For instance, the East and Gulf coasts are prone to hurricanes, while the West Coast is more likely to experience earthquakes. Yet others, such as pandemics and bioterrorism, can occur anywhere. Your plan should be based on your probability research and be specific to the area of the country where you are located.

The results of this survey are communicated to community emergency response agencies. Resources assessed include equipment, medical supplies, food, water, patient care activities, utility systems, available staff, security, protective equipment, and transportation. You are part of a community that can offer your hospital additional resources and, at the same time, you are charged with providing services to the community.

Your hospital should have plans for an incident command center that activates prior to or during a disaster. The first step is for staff to call in for instructions if they are off site. Up-to-date contact information for you and your key staff is essential. Several organizations offer analysis tools to help you with this process, including the California Hospital Association, the National Incident Management System, and the Hospital Emergency Incident Command Center.

The advantage of a recognized disaster plan is that it provides a common language to use during an event. An example is an order to “lock down,” which alerts staff that only certain entrances and exits will be open. Different locations for an unexpected influx of patients may be color coded. If everyone knows that “orange” areas are isolated and “green” exits are closed during a suspected bioterrorism attack, personnel assignment is easier. This facilitates good communication among the staff.

During a disaster, calls are routed through a command center. Department leaders routinely report to and communicate a department’s status to the command center at regular intervals. This allows for appropriate distribution of manpower and communication of information.

Disasters often force staff to assume new or unfamiliar roles. Training staff involves both study and drills. Everyone should be aware of their role in the EOP and participate conscientiously in drills to refine it. Hospitals practice for disasters as part of countywide drills, usually at least twice per year, with scenarios chosen to represent the most likely disasters in those areas. Supervisors and team leaders should take these exercises seriously and provide pointed and clear feedback to staff on their performance. Remember: Drills are simply idealized scenarios; in real disasters, the unexpected happens and people may be called on to do more than their usual share of work. Exemplary employee performance should be noted and cited.

Periodic tabletop exercises are also helpful and can be provided as in-service training. Exercises can be customized for your facility and should be simple and focused on the three to five most likely disaster scenarios for your area. If you are located in areas prone to earthquakes, for example, such events may destroy roads, making it impossible for many hospital staff to get to work while simultaneously increasing traffic at the trauma center. A disaster exercise may identify those personnel least likely to be absent (ie, those who live nearby) and help them develop skills beyond their primary responsibilities.

Exercises such as this allow you to describe the variables you may encounter in written, real-time communications with other internal participants. Don’t short change the use of this tool. The mental exercise is very valuable, and when staff are focused on a common problem and charged with developing solutions, they often become more creative.

If you are a leader or a supervisor, you must not only master the plan’s components but also pass on your knowledge to your employees. You need to convey the message that “we will all get through this together,” no matter what the situation. The plan is created for all departments in your facility and is part of a hospitalwide plan. As a supervisor, you will probably have creative input in developing, reviewing, and (if necessary) modifying the plan. Community resources are also available to help you.

Leaders and supervisors experience additional stress during a disaster and may be personally affected to a degree that impairs their actions. In the previous example, department heads may be unable to make it to the hospital. In that case, the EOP provides a template of actions that can occur during times of great duress and can serve as a guide for the department in a supervisor’s absence. The plan should not be supervisor dependent; all staff should know the location of the plan manual and be familiar with the steps in the process. A quarterly in-service for staff is recommended to ensure action when needed.

An audit of currently available manpower is vital. It should identify which staff members are available during each shift, which are signed up to come into work during a disaster, and which can come in quickly (eg, those with limited family obligations or who live in close proximity). Quarterly updates to the manpower audits ensure that the latest information is available at a moment’s notice. A signed commitment from employees to help during a disaster will allow others in your department to plan ahead. A call tree should be created to facilitate quick contact with off-site employees once a disaster has occurred.

Your hospitalwide plan should contain an employee pool wherein staff members can be reassigned to areas other than their own during a disaster. Outside qualified personnel can also be used after an expedited credentialing process to ensure the basic credentials are real. Your human resources or medical staff office can assist with this option.

A checklist should be created that includes simple instructions and flowcharts to assist with on-the-spot training. You may be working with personnel from other departments who have been assigned to your area; pairing new and inexperienced staff with those who are more experienced is recommended. By having a checklist, the new person has a resource for any questions or concerns. A simplified job description that incorporates infection-control processes, food storage, and other crucial information may also be helpful. Under stress, staff cannot absorb an abundance of policies and procedures in detail, so your instructions should be simple yet comprehensive.

During a disaster, personnel will likely work long hours, so policy regarding the care of family members or pets should be in place, as it is difficult to work effectively if your mind is on your loved ones at home. Many hospitals allow family on the premises and make accommodations for pets. Child and elder care and family sleeping areas can be part of the hospital plan. Families should be advised to bring supplies with them, such as medications, blankets, water, and ready-to-eat foods. Consider the need for infant formula and baby food, especially if your facility does not offer obstetric, infant, or pediatric care.

A pandemic disaster may rapidly deplete your resources, making your staff as vulnerable as the public. Your staff should receive vaccinations in advance in preparation for any infectious disease.

Duties specific to food and nutrition departments include ensuring the availability of a minimum of seven days’ worth of food. During disasters, local and regional food-delivery systems may be impacted by road blockages or damage to vendor facilities. An on-site reserve food supply is critical for survival. This reserve should be stored in a designated area and not include your current food supplies. Commonly stored foods include dried or canned milk, canned meats, canned vegetables, canned or dried fruits/juices, soups, and dry goods such as rice, noodles, and potatoes. Stored food should be inventoried regularly and rotated into the general food supply when expiration dates near. Special emergency menus should be created to utilize these foods.

A list of what is stored should be available at all times. Regulatory agency inspectors often ask to see the list of stored disaster food supplies and analyze the content and amount on hand. Table 1 lists a sample disaster food supply inventory by type.

The amount of food should be determined based on the average daily census and the projected number of staff. Consider allowing for extras in your calculations since patients and staff may have family members with them. If prior warning of a disaster is received, order additional supplies in advance. Visit local markets and stock up, and arrange for extra deliveries and amounts from your current vendors.

Depending on where your facility is located, consider the optimal location for storing disaster supplies. If hurricanes and flooding are common in your area, avoid lower-level storage. If located in an earthquake-prone area, store food close to an outside wall and exit. This area should be clearly marked on the outside of the building.

Food and water supply security is a significant concern; knowing the source of your food is the best defense. In the Bioterrorism Act of 2002, as part of the post-9/11 attack response, the FDA added regulations to help protect the food supply. New laws require all U.S. and foreign companies to record the origin and destination of imported food. However, the FDA inspects less than 1% of imported foods, and the foreign food supply chain has little oversight.

It is your responsibility as a leader to stay current regarding laws related to your food deliveries and where those items originated. This allows for a quick response when these food items are needed. Be proactive for any signs of tampering, such as a foul odor, unusual appearance, or unidentified drainage. All receiving and food preparation staff should be on the lookout for tainted food. Routine staff education is recommended.

Immediate Response
Producing patient meals is the dietetics department’s top priority followed by staff meals. Previously written emergency menus will help with planning meals and managing food supplies. If possible, incorporate your current supply into your stored reserves to provide more than seven days’ worth of meals. Depending on the severity of the event and how widespread the disaster, your facility may need the additional food store.

Food, water, and other resources during the event need to be monitored, as this will allow for adjustments to conserve resources. Depending on the type of disaster, normal delivery routines may be impaired. In a hurricane, for example, patients may be moved out of their rooms and into hallways to protect them from breaking windows and flying debris. This will make it impossible for food carts to get through, so designate a central drop-off area for carts and hand deliver trays. Patient identification will need to be done per your hospital policy and procedure to ensure the trays are delivered to the correct patients. All patient safety processes should remain in play.

If flooding is a concern, your food production area may need to be relocated to a higher floor. Identify portable equipment, such as food preparation tables, which can be moved quickly to the desired location to provide storage and preparation surfaces.

A plan of how you will communicate to your staff during a disaster should be established. During the actual event, knowledge of the current state of affairs reduces stress. Consider hourly or routine meetings with the entire group or the dissemination of written updates. The updates should include words of encouragement, restatement of the chain of command if additional help is needed, the status of the event in relation to internal and external updates, and any additional newsworthy items.

There is no guarantee that the phones will be working during a disaster, but you must communicate often. A centrally located bulletin board can be used to post the latest information. A runner should periodically check on all workstations to assess and report back on any additional needs. Other communication mechanisms include fax machines, cell phones, satellite phones, and amateur radio.

To help reduce patient anxiety and panic, all dietary and clinical nutrition staff with direct patient contact should be coached to conceal fear. It is very important to show confidence to staff, patients, and patient families. If well prepared, they should have faith in the facility and the disaster plan.

However, staff should be aware that some activities will increase patient anxiety. For example, security is an issue. Staff must secure outside doors and windows to prevent unwanted entry and reduce the number of entry and exit points in accordance with the EOP. Locking out may look like locking in to some patients; how staff portray that activity will impact how patients perceive it.

Recovery After the Event
Preagreements with local food distributors for postdisaster food delivery are a must. These contracts, or memoranda of agreement, give your facility priority status for food delivery. It is recommended that you have multiple agreements with different vendors, including those not in your immediate geographic area. If local infrastructure is severely damaged, this may be your only source of food.

Food resource conservation should always be in consideration, and thus you may be forced to curtail certain services. Patients requiring special diets are a priority, but some diets can be curtailed until the disaster situation passes. Medical staff can help prioritize dietary requirements.

You may receive an influx of additional patients after the event, which further stresses the available resources. Being part of a larger healthcare company has benefits; the parent company can provide help—even helicopter deliveries of medical supplies, food, and water. Additional personnel can be flown in and evacuation arrangements can also be made for patients, doctors, and employees. During Hurricane Katrina, the Hospital Corporation of America provided contracted helicopter assistance for evacuation in a timely manner. Cooperative arrangements with larger facilities nearby should be established.

What They Don’t Tell You in the Manuals
While disasters impact individuals uniquely, we know they affect performance and add stressors. Consider caffeine withdrawal and its effects on your staff. Once the coffee and tea run out, the headaches set in. Maintain an ample supply of aspirin, acetaminophen, and ibuprofen to battle withdrawal symptoms. Chocolate candy and most sodas are good sources of caffeine to have on hand as well.

Personal prescriptions are a serious matter. Staff may be unable to return home from their shift or may run out of needed medications. Consider, for example, a staffer who needs seizure medications on a daily basis. Working with human resources, you may wish to identify such situations and connect with medical staff who are likely to be present during and after a disaster. They may be able to provide support and work with the on-site pharmacy to meet critical needs. Always carry your own critical medications with you and advise employees to do likewise.

Hygiene is essential for morale and patient safety. For instance, if plumbing is impaired or running water is unavailable, kitty litter in a bedpan will suffice in a pinch. Keep a spare set of clothes (including undergarments) and toiletries in your car or at work. Keep your vehicle’s gasoline tank more than half full. Gas siphoned from cars powered emergency generators in New Orleans hospitals during Katrina when the stored gas reserves were exhausted.

Emotional stress takes its toll on all employees. Often workers are cut off from the outside world and become worried about their family, pets, friends, and homes. Offering constant support and information is critical. Keep rumors at bay and share information from the county disaster headquarters and police department. Assure employees that they are not alone.

If possible, provide a place of silence and rest. You can designate an office for this purpose. Employees can also use this location to facilitate outside communication with families once it’s established. Having a safe place to release an occasional bout of tears or discuss one’s fears may be helpful.

Plan for a designated sleeping area. Provide as much privacy as possible and ensure that it is in a safe location. Armed security is also necessary. Work with your security department to plan for the protection of people and property. Unfortunately, firearms may be necessary as a deterrent to crime.

Be Prepared
Disasters are a part of our lives personally and professionally. The more you prepare in advance, the better you will fare during the actual event. Develop your departmental plan in detail and drill repeatedly with staff. Create simple, easy-to-follow job descriptions and checklists for untrained help. Communication during the event is critical to combat the natural stressors that occur during and after disasters. Remain calm and project a compassionate and knowledgeable demeanor. Your leadership can hold the department together in the face of the unexpected.

— Karen Meno, BS, MBA, RD, LD, CPHQ, HCRM, is a licensed and registered dietitian, licensed healthcare risk manager, and author for Nutrition Dimension. She has served as a quality director and vice president for quality and risk at Largo Medical Center in Florida.

 

Learning Objectives
After completing this continuing education exercise, the student should be able to:

1. Identify the four components of disaster preparedness.
2. Describe how hospitals interact with the community to conduct hazard vulnerability assessments and prepare an emergency operations plan.
3. List three components of an audit of available manpower resource as it relates to disaster preparedness.
4. List common foods to keep in reserve for emergency use.
5. Discuss how to set up internal communications systems that do not depend on working telephones.
6. Discuss how to serve staff medical and hygiene needs during extended duty.

Examination
1. The Hazard Vulnerability Analysis tool helps a facility to:
a. identify the quickest way to exit during a disaster.
b. identify the most common types of disasters that occur in your geographic area.
c. list available resources such as equipment, supplies, patient care activities, utility systems, available staff, security, protective equipment, and transportation.
d. b and c
e. None of the above

2. Every hospital must have a written, current, and available Emergency Operations Plan.
a. True
b. False

3. Which of the following resources provides a model for managing a disaster?
a. National Incident Management System
b. Hospital Emergency Incident Command Center
c. Hospital Incident Company and Command Plan
d. Facilities’ Incident Assessment and Action Plan
e. a and b

4. Which of the following should be done to plan for manpower during a disaster?
a. Maintain manpower resource audits of currently available staff.
b. Identify staff members who can come in quickly and who live in close proximity to the hospital.
c. Obtain a signed commitment from employees to help during a disaster or the aftermath.
d. Develop a plan to utilize noncredentialed personnel if necessary.
e. All of the above

5. Food and nutrition departments should have this amount of stored food supply on hand at all times?
a. Three days
b. Four days
c. Five days
d. Seven days or more

6. Postdisaster food-delivery plans contain which of the following steps?
a. Contact government emergency organizations to request food.
b. Wait for volunteer organizations to deliver food and supplies.
c. Make arrangements with local food distributors to deliver food and supplies postdisaster.
d. Have multiple agreements with different vendors.
e. c and d

7. Communication with staff is key to reducing stress during a disaster. Which of the communication methods listed below are best to reduce stress?
a. Word of mouth
b. Routine meetings with the entire staff
c. Handwritten updates posted in a central location or hand delivered to staff
d. Intermittent outside news broadcasts
e. b and c

8. New federal regulations following the 9/11 attacks require that all U.S. and foreign companies record the origin and destination of imported foods.
a. True
b. False

9. Employees may be in a new role in the food and nutrition department during a disaster. Training before beginning work should include the following:
a. A review of all policies and procedures must occur before working and a posttest taken and passed.
b. A review of a simplified job description that incorporates infection control practices, food storage, food handling, and other crucial information.
c. Review of check sheets that include simple instructions.
d. a and b
e. b and c

10. An emergency food supply storage location should be based on the following:
a. Anywhere in the department or hospital
b. If prone to flooding, above the lower level
c. If prone to earthquakes, close to an outside wall that is clearly marked from the outside
d. None of the above
e. b and c

 

Table 1: Sample Disaster Food Supply Inventory

Food Item	Suggested Serving Size	Food Item	Suggested Serving Size
Tuna Fish (canned)	1/2 cup	Peanut Butter (jar)	1 oz (2 T)
Chicken (canned)	1/2 cup	Chicken Noodle Soup (canned)	1 cup
Chicken and Dumplings (canned)	1 cup	Split Pea Soup (canned)	1 cup
Macaroni and Cheese (dry)	1 cup	Vegetable Beef Soup (canned)	1 cup
Beef Stew (canned)	1 cup	Carrots (canned)	1/2 cup
Spaghetti with Meat Sauce (canned)	1 cup	Green Beans (canned)	1/2 cup
Beef Ravioli (canned)	1 cup	Mixed Vegetables (canned)	1/2 cup
Beef Chunks (canned)	1/2 cup	Beets (canned)	1/2 cup
Corned Beef Hash (canned)	1 cup	Vegetable Juice (canned)	1/2 cup
Chili (canned)	1 cup	Tomato Juice (canned)	1/2 cup
Peas and Carrots (canned)	1/2 cup	Pork and Beans (canned)	1/2 cup
Diced Potatoes (canned)	1/2 cup	Corn (canned)	1/2 cup
Mashed Potatoes (dry)	1/2 cup	Lima Beans (canned)	1/2 cup
Red Beans (canned)	1/2 cup	Milk (dry)	1 cup
Garbanzo Beans	1/2 cup	Pudding (dry)	1 cup
Green Peas (canned)	1/2 cup	Cranberry Juice (canned)	3/4 cup
Apple Juice (canned)	1/2 cup	Applesauce (canned)	3/4 cup
Mixed Fruit (canned)	1/2 cup	Citrus Salad (jar)	1/2 cup
Grape Juice (canned)	3/4 cup	Pears (canned)	3/4 cup
Pineapple Chunks (canned)	3/4 cup	Water (bottled)	1 cup